Use of the Sentinel Lymph Node Technique Compared to Complete Inguino-femoral Lymph Node Removal in Patients with Invasive Vulvar Cancer in Germany

In the current S2 guidelines, the standard surgical therapy for patients with vulvar cancer also includes inguino-femoral lymphadenectomy. However, in view of the severe side-effects associated with this approach such as problems with wound healing, lymphoceles and lymphoedema, the search is on for alternative treatments that could decrease treatment-associated morbidity and improve patients' quality of life, particularly for node-negative patients. The sentinel lymph node technique is currently the gold standard in the treatment of unifocal breast cancer (clinically negative axilla), and studies on the use of this technique in the treatment of vulvar cancer are promising. To date, the diagnostic accuracy of this method in vulvar cancer has only been evaluated in a single, one-arm, non-randomised, multicentre study. In preparation for a multicentre study, in 2010 we surveyed 41 German hospitals to investigate how often they used the sentinel lymph node technique compared to inguino-femoral lymphadenectomy. The hospitals were grouped according to hospital size and number of patients treated for vulvar cancer. The decision criteria to determine the type of procedure performed were also investigated. Finally, the hospitals were asked whether they would be willing to participate in a prospective clinical study to evaluate the sentinel lymph node technique in patients with vulvar cancer. The majority of surgeons questioned (73 %) already had some experience with this technique in patients with vulvar cancer. In our survey, 27 % of hospitals carried out inguino-femoral lymphadenectomy, 10 % used the sentinel lymph node technique, and 63 % used both methods. In 24 % of hospitals, the standard procedure consisted of the sentinel lymph node technique supplemented by inguino-femoral lymphadenectomy. Only 20 % of the institutions surveyed in our study carried out sentinel lymph node biopsy alone in accordance with the criteria of the consensus recommendations. The majority of the investigated institutions were willing to participate in a randomised prospective clinical study to evaluate the effectiveness of sentinel lymph node sampling in patients with vulvar cancer.

Lymphedema of the breast as a symptom of internal diseases or side effect of mTor inhibitors

A common situation presented in any clinical facility is a woman with swelling and redness of the breast. Diagnosis upon suspicion is often mastitis or inflammatory breast cancer, which are popular and well-known diseases of the breast. However, there is one main differential diagnosis which has to be taken into consideration: lymphedema of the breast. Twenty patients with internal diseases presented in our Breast Care Unit over a 4-year period with breast-affecting lymphedema. The patients suffered from cardiac failure, nephrotic syndrome, liver failure, lymphadenopathy, and central vein occlusion. Additionally, we identified 5 patients with a history of organ transplantation and under immunosupressive medication with sirolimus or everolimus. These mTor inhibitors are known to have unwanted side effects such as unilateral or bilateral upper/lower extremity peripheral edema or facial/eyelid edema, but as we know, isolated lymphedema of the breast represents a previously unreported complication.

Analysis of the impact of PAPP-A, free β-hCG and nuchal translucency thickness on the advanced first trimester screening

OBJECTIVES

The intention of this study is to analyze the impact of the single parameters NT, PAPP-A and free β-hCG used in combined first trimester screening and to determine their contribution in the risk assessment.

METHODS

A retrospective risk assessment on the advanced first trimester screening (AFS) algorithm was made to determine the effect of a particular parameter while the remaining ones were fixed for calculation. Afterward data were recalculated by the AFS module. Test performance was measured by receiver operating characteristics (ROC) curves and their area under curve (AUC).

RESULTS

Among the 14,862 cases are 14,748 healthy fetuses, 86 with trisomy 21, 22 with trisomy 18 and 6 with trisomy 13. Some settings obtain at default cut-off a very high sensitivity. However, a lack of specificity, as a high false-positive rate, too. The ROC analysis was best for NT, followed by PAPP-A. Free β-hCG showed the lowest AUC. Combining PAPP-A and free β-hCG offered a better AUC than each parameter alone. Best test performance was obtained by including all three parameters.

DISCUSSION

A detection rate of 69 % for testing NT discretely is in order with present study data. PAPP-A is following and free β-hCG is not useful with a test positive rate of about a third. The detection rate of the biochemical parameters combined is higher than for NT alone, but results in a five times higher punctuation rate. All parameters together in the AFS provide the best test performance. The impact of each parameter NT, PAPP-A and free-β-hCG in a combined test strategy is nearly a third. Thus, every single parameter is needed to provide a high detection rate for all of the trisomies and minimize the number of unnecessary invasive diagnostics.

A phase II trial (AGO 2.11) in platinum-resistant ovarian cancer: a randomized multicenter trial with sunitinib (SU11248) to evaluate dosage, schedule, tolerability, toxicity and effectiveness of a multitargeted receptor tyrosine kinase inhibitor monotherapy

BACKGROUND

Recurrent platinum-resistant ovarian cancer usually has a poor outcome with conventional chemotherapeutic therapy and new treatment modalities are warranted. This phase II study was conducted to evaluate sunitinib, an oral antiangiogenic multitargeted tyrosin kinase inhibitor, in this setting.

MATERIAL AND METHODS

The primary end point of this randomized phase II trial was the objective response rate according to RECIST criteria and/or Gynecologic Cancer InterGroup CA125 response criteria to sunitinib in patients with recurrent platinum-resistant ovarian cancer who were pretreated with up to three chemotherapies. A selection design was employed to compare two schedules of sunitinib (arm 1: 50 mg sunitinib daily orally for 28 days followed by 14 days off drug; and arm 2: 37.5 mg sunitinib administered daily continuously).

RESULTS

Of 73 patients enrolled, 36 patients were randomly allocated to the noncontinuous treatment arm (arm 1) and 37 patients were randomly allocated to the continuous treatment arm (arm 2). The mean age was 58.8 and 58.5 years, respectively. We observed six responders (complete response + partial response) in arm 1 (16.7%) and 2 responders in arm 2 (5.4%). The median progression-free survival (arm 1: 4.8 [2.9-8.1] months; arm 2: 2.9 [2.9-5.1] months) and the median overall survival (arm 1: 13.6 [7.0-23.2] months; arm 2: 13.7 [8.4-25.6] months) revealed no significant difference. Adverse events included fatigue as well as cardiovascular, gastrointestinal and abdominal symptoms, hematologic and hepatic laboratory abnormalities. Pattern and frequency of adverse events revealed no substantial differences between both treatment groups.

CONCLUSIONS

Sunitinib treatment is feasible and moderately active in relapsed platinum-resistant ovarian cancer. The noncontinuous treatment schedule should be chosen for further studies in ovarian cancer.

[Intraoperative pathological rapid investigations in breast surgery]

In breast surgery intraoperative frozen sections for the diagnosis of malignancy has lost impact and has largely been replaced by preoperative core needle biopsies. Nevertheless, there is still need for immediate pathological investigation of native breast tissue during surgery due to three reasons: (1) macroscopic and microscopic evaluation of resection margins, (2) the histological analysis of sentinel lymph nodes in order to circumvent secondary axillary surgery and (3) the preparation of native tissue for tumor banking or measurement of biomarkers. Because histology provides only a facultative component of immediate pathological examination of breast specimens during surgery, the term frozen section does not seem to be appropriate anymore. Intraoperative evaluation of resection specimens by pathologists provides surgically relevant information immediately, guarantees standardized preparation and fixation of specimens and enables tissue banking of native tissue for assessment of biological markers.

Importance of HPV Genotyping for the Screening, Therapy and Management of Cervical Neoplasias

In the last decade, the detection of human papillomaviruses (HPV) has become increasingly important in cervical cancer screening and the treatment of cancer precursors. HPV screening is recommended for the further evaluation of abnormal Pap tests or during follow-up after treating precancerous lesions. Several randomised controlled studies have shown that screening for cervical cancer using HPV detection can be more effective than cytology alone. Genotyping of different high-risk HPV (hrHPV) types obtained from smear tests has not yet gained widespread acceptance in clinical practice. However, significant differences have been noted in the oncogenicity of hrHPV genotypes. HPV 16 is by far the most common and oncogenic genotype. Genotyping of hrHPV could be helpful for the risk stratification of HPV-positive women.

Characterisation of the learning curve of caesarean section

INTRODUCTION

Caesarean section is one of the common operations in medicine. As almost all interventions, the quality of the operation depends on the training and skills of the surgeon. This study aims at characterising the learning curve of caesarean section.

MATERIAL AND METHODS

All patients with a singleton pregnancy who underwent a caesarean section between 2000 and 2009 in our university hospital were identified. We analysed datasets from beginners (no experience at all) and experienced surgeons (>300 caesarean sections, consultant) comparing the parameter incision-suture time (I-S time), incision-delivery time (I-D time), maternal blood loss, umbilical artery pH (ua-pH), APGAR score after 1, 5 and 10 min, mean time in hospital and postoperative complications. In addition, the first 100 caesarean sections of each beginner surgeon were divided in groups of 10 (1-10, 11-20, etc.) and analysed using the above-mentioned parameters. The learning curves were calculated.

RESULTS

2,515 of 3,844 operations were carried out by 23 experienced surgeons versus 1,329 operations by 22 beginners. The I-S time and I-D time was significantly higher in the beginners group than in the experienced surgeon's group (45.9 vs. 41.3 min, p < 0.001). Furthermore, for the first ten caesarean sections, the mean I-S time (47.9 min, 95% CI 45.7-50.0 min vs. 31-40th caesarean section with 43.1 min, 95% CI 40.9-45.3 min, p < 0.0001) and I-D time (9.5 min, 95% CI 8.6-10.5 min vs. 71-80th caesarean section with 4.8 min, 95% CI 4.2-5.4 min, p < 0.0001) was significantly higher than of the subsequent datasets of ten operations, showing a typical learning curve.

CONCLUSION

The learning curve for the total operation time and incision-delivery time reaches a flatter part after 10-15 caesarean sections. However, the learning process is highly individualised and difficult to predict, so that supervision and evaluation of the trainee by an experienced surgeon is important.

P2-10-07: Triple-Negative Breast Cancer May Have Ultrasonographic Features Mimicking Nonmalignant Lesions

Background

Triple-negative breast cancer (TNBC) is known to have unique molecular, clinical and pathologic characteristics. Histological studies illustrate high mitotic counts, geographic necrosis, pushing borders of invasion, and stromal lymphocytic response. These growth patterns may also affect the appearance of TNBC in ultrasound.

Our study evaluates the ultrasonographic features of TNBC according to the ACR BI-RADS®-US classification system and compares these features with non-TNBC.

Materials and methods: Data of 385 consecutive breast cancer cases were collected from our hospital database. Digitally recorded ultrasound images were available for 292 patients. These images were interpreted according to the BI-RADS® system by an examiner blinded to the patients’ characteristics and histological results. The ultrasonographic features of TNBC (n=45) and non-TNBC (n=247) were compared using Fisher's exact test.

Results: TNBC was more common in younger patients and exhibited higher tumor grades and more advanced tumor stages. Focusing on the ultrasound features, TNBC was more likely to exhibit round or oval shape (35.5% versus 25.9% in non-TNBC) and the margin of TNBC was more frequently described as microlobulated (48.9% versus 37.7% in non-TNBC) instead of angular or spiculated. In TNBC the echogenic halo was significantly less often observed (46.7% versus 64.4% in non-TNBC, p=0.0302) and we found less architectural distortions (65.5% versus 84.3% in non-TNBC, p=0.0341). Regarding the posterior acoustic features, an enhancement was significantly more often observed in TNBC (26.7% versus 13.0% in non-TNBC, p=0.0391).

Discussion: TNBC and non-TNBC seem to have different ultrasonographic features. This can be explained by the unique pathologic profile of this breast cancer subtype. As some of the distinct ultrasound criteria of TNBC are associated with benign masses, TNBC may mimic nonmalignant lesions. Being familiar with these features can avoid false-negative classification of TNBC.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-10-07.

Pitfalls of ultrasonographic yolk sac measurement

PURPOSE

Novel aneuploidy screening has been suggested for measuring the yolk sac during very early pregnancy. However, in a pilot study the measured diameters differed up to 29 % from the overall average. The aim of this study was to analyze the impact of image magnification on yolk sac measurement.

MATERIALS AND METHODS

From November 3, 2009 to July 28, 2010, 119 yolk sac measurements were performed. During each examination, each yolk sac was examined once with standard image magnification and once by live scan zoom.

RESULTS

The measurement values were 5 % smaller in the standard image. The mean relative ratio (RR), median RR, and standard deviation (SD) were 0.951, 0.950, and 0.103 mm, respectively (95 % CI 0.744 to 1.158 mm). Regarding absolute differences, the mean, median, and standard deviation were -0.222 mm, -0.220 mm, and 0.473 mm, respectively, (95 % CI -1.169 to + 0.725 mm). With standard zoom (magnified images), the SD was 1.142 mm (1.099 mm).

CONCLUSION

Five criteria should be regarded for optimal image settings: image magnification during live scan, optimal gain setting, enhanced gamma level, median section plane, and out-to-out caliper placement.

High frequency and allele-specific differences of BRCA1 founder mutations in breast cancer and ovarian cancer patients from Belarus

Breast cancer and ovarian cancer are common malignancies in Belarus accounting for about 3500 and 800 new cases per year, respectively. For breast cancer, the rates and age of onset appear to vary significantly in regions differentially affected by the Chernobyl accident. We assessed the frequency and distribution of three BRCA1 founder mutations 5382insC, 4153delA and Cys61Gly in two hospital-based series of 1945 unselected breast cancer patients and of 201 unselected ovarian cancer patients from Belarus as well as in 1019 healthy control females from the same population. Any of these mutations were identified in 4.4% of the breast cancer patients, 26.4% of the ovarian cancer patients and 0.5% of the controls. In the breast cancer patients, BRCA1 mutations were strongly associated with earlier age at diagnosis, with oestrogen receptor (ER) negative tumours and with a first-degree family history of breast cancer, although only 35% of the identified BRCA1 mutation carriers had such a family history. There were no marked differences in the regional distribution of BRCA1 mutations, so that the significant differences in age at diagnosis and family history of breast cancer patients from areas afflicted by the Chernobyl accident could not be explained by BRCA1. We next observed a higher impact and a shifted mutational spectrum of BRCA1 in the series of Byelorussian ovarian cancer patients where the three founder mutations accounted for 26.4% (53/201). While the Cys61Gly mutation appeared underrepresented in ovarian cancer as compared with breast cancer cases from the same population (p = 0.01), the 4153delA mutation made a higher contribution to ovarian cancer than to breast cancer (p < 0.01). BRCA1 mutations were significantly enriched among ovarian cancer cases with a first-degree family history of breast or ovarian cancer, whereas the median age at ovarian cancer diagnosis was not different between mutation carriers and non-carriers. Taken together, these results identify three BRCA1 founder mutations as key components of inherited breast and ovarian cancer susceptibility in Belarus and might have implications for cancer prevention, treatment and genetic counselling in this population.